July 2019 Performance Drug List - Standard Control for ... · colchicine tablet probenecid COLCRYS...
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Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit Caremark.com or contact a CVS Caremark Customer Care representative. July 2019 Effective 08/01/2019 Performance Drug List - Standard Control for Clients with Advanced Control Specialty Formulary ® The CVS Caremark ® Performance Drug List - Standard Control for Clients with Advanced Control Specialty Formulary ® is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should be considered the first line of prescribing. If there is no generic available, there may be more than one brand-name medicine to treat a condition. These preferred brand-name medicines are listed to help identify products that are clinically appropriate and cost-effective. Generics listed in therapeutic categories are for representational purposes only. This is not an all-inclusive list. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. PLAN MEMBER Your benefit plan provides you with a prescription benefit program administered by CVS Caremark. Ask your doctor to consider prescribing, when medically appropriate, a preferred medicine from this list. Take this list along when you or a covered family member sees a doctor. Please note: • Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the U.S. Food and Drug Administration (FDA) may not be covered upon release to the market. • You may be responsible for the full cost of non-formulary products that are removed from coverage. • For specific information regarding your prescription benefit coverage and copay 1 information, please visit Caremark.com or contact a CVS Caremark Customer Care representative. • CVS Caremark may contact your doctor after receiving your prescription to request consideration of a drug list product or generic equivalent. This may result in your doctor prescribing, when medically appropriate, a different brand-name product or generic equivalent in place of your original prescription. • In most instances, a brand-name drug for which a generic product becomes available will be designated as a non- preferred option upon release of the generic product to the market. HEALTH CARE PROVIDER Your patient is covered under a prescription benefit plan administered by CVS Caremark. As a way to help manage health care costs, authorize generic substitution whenever possible. If you believe a brand-name product is necessary, consider prescribing a brand name on this list. Please note: • Generics should be considered the first line of prescribing. • This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. The member’s specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the FDA may not be covered upon release to the market. • The member's prescription benefit plan may have a different copay 1 for specific products on the list. • Unless specifically indicated, drug list products will include all dosage forms. • Log in to Caremark.com to check coverage and copay 1 information for a specific medicine. ANALGESICS § NSAIDs diclofenac sodium ibuprofen suspension meloxicam naproxen 2 § NSAIDs, COMBINATIONS diclofenac sodium- misoprostol § NSAIDs, TOPICAL diclofenac sodium gel 1% (except NDC^ 69499031866) diclofenac sodium solution § COX-2 INHIBITORS celecoxib § GOUT allopurinol colchicine tablet probenecid COLCRYS ULORIC § OPIOID ANALGESICS codeine-acetaminophen fentanyl transdermal fentanyl transmucosal lozenge hydrocodone-acetaminophen hydromorphone hydromorphone ext-rel methadone morphine morphine ext-rel morphine suppository oxycodone oxycodone-acetaminophen tramadol tramadol ext-rel ABSTRAL BELBUCA BUTRANS EMBEDA HYSINGLA ER NUCYNTA NUCYNTA ER OXYCONTIN SUBSYS ANTI-INFECTIVES ANTIBACTERIALS § CEPHALOSPORINS cefdinir cefprozil cefuroxime axetil cephalexin SUPRAX § ERYTHROMYCINS / MACROLIDES azithromycin clarithromycin clarithromycin ext-rel erythromycins DIFICID § FLUOROQUINOLONES ciprofloxacin ciprofloxacin ext-rel levofloxacin moxifloxacin § PENICILLINS amoxicillin amoxicillin-clavulanate dicloxacillin penicillin VK § TETRACYCLINES doxycycline hyclate minocycline tetracycline § ANTIFUNGALS fluconazole itraconazole terbinafine tablet ANTIVIRALS § CYTOMEGALOVIRUS AGENTS valganciclovir § HERPES AGENTS acyclovir valacyclovir
Transcript of July 2019 Performance Drug List - Standard Control for ... · colchicine tablet probenecid COLCRYS...
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit Caremark.com or contact a CVS Caremark Customer Care representative.
July 2019 Effective 08/01/2019
Performance Drug List - Standard Control for Clients with Advanced Control Specialty Formulary®
The CVS Caremark® Performance Drug List - Standard Control for Clients with Advanced Control Specialty Formulary® is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should be considered the first line of prescribing. If there is no generic available, there may be more than one brand-name medicine to treat a condition. These preferred
brand-name medicines are listed to help identify products that are clinically appropriate and cost-effective. Generics listed in therapeutic categories are for representational purposes only. This is not an all-inclusive list. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics.
PLAN MEMBER
Your benefit plan provides you with a prescription benefit program administered by CVS Caremark. Ask your doctor to consider prescribing, when medically appropriate, a preferred medicine from this list. Take this list along when you or a covered family member sees a doctor.
Please note:
• Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the U.S. Food and Drug Administration (FDA) may not be covered upon release to the market.
• You may be responsible for the full cost of non-formulary products that are removed from coverage.
• For specific information regarding your prescription benefit coverage and copay1 information, please visit Caremark.com or
contact a CVS Caremark Customer Care representative.
• CVS Caremark may contact your doctor after receiving your prescription to request consideration of a drug list product or generic equivalent. This may result in your doctor prescribing, when medically appropriate, a different brand-name product or generic equivalent in place of your original prescription.
• In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market.
HEALTH CARE PROVIDER
Your patient is covered under a prescription benefit plan administered by CVS Caremark. As a way to help manage health care costs, authorize generic substitution whenever possible. If you believe a brand-name product is necessary, consider prescribing a brand name on this list.
Please note:
• Generics should be considered the first line of prescribing.
• This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. The member’s specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the FDA may not be covered upon release to the market.
• The member's prescription benefit plan may have a different copay1 for specific products on the list.
• Unless specifically indicated, drug list products will include all dosage forms.
• Log in to Caremark.com to check coverage and copay1
information for a specific medicine.
ANALGESICS
§ NSAIDs
diclofenac sodium
ibuprofen suspension
meloxicam
naproxen 2
§ NSAIDs, COMBINATIONS
diclofenac sodium-misoprostol
§ NSAIDs, TOPICAL
diclofenac sodium gel 1%
(except NDC^ 69499031866)
diclofenac sodium solution
§ COX-2 INHIBITORS
celecoxib
§ GOUT
allopurinol colchicine tablet probenecid
COLCRYS
ULORIC
§ OPIOID ANALGESICS
codeine-acetaminophen
fentanyl transdermal fentanyl transmucosal
lozenge
hydrocodone-acetaminophen
hydromorphone
hydromorphone ext-rel methadone
morphine
morphine ext-rel morphine suppository
oxycodone
oxycodone-acetaminophen
tramadol tramadol ext-rel ABSTRAL
BELBUCA
BUTRANS
EMBEDA
HYSINGLA ER
NUCYNTA
NUCYNTA ER
OXYCONTIN
SUBSYS
ANTI-INFECTIVES
ANTIBACTERIALS
§ CEPHALOSPORINS
cefdinir cefprozil cefuroxime axetil cephalexin
SUPRAX
§ ERYTHROMYCINS / MACROLIDES
azithromycin
clarithromycin
clarithromycin ext-rel erythromycins
DIFICID
§ FLUOROQUINOLONES
ciprofloxacin
ciprofloxacin ext-rel levofloxacin
moxifloxacin
§ PENICILLINS
amoxicillin
amoxicillin-clavulanate
dicloxacillin
penicillin VK
§ TETRACYCLINES
doxycycline hyclate
minocycline
tetracycline
§ ANTIFUNGALS
fluconazole
itraconazole
terbinafine tablet
ANTIVIRALS
§ CYTOMEGALOVIRUS AGENTS
valganciclovir
§ HERPES AGENTS
acyclovir valacyclovir
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit Caremark.com or contact a CVS Caremark Customer Care representative.
§ INFLUENZA AGENTS
oseltamivir RELENZA
§ MISCELLANEOUS
clindamycin
ivermectin
linezolid
metronidazole
nitrofurantoin
sulfamethoxazole-trimethoprim
EMVERM
XIFAXAN 550 MG
ANTINEOPLASTIC
AGENTS
HORMONAL ANTINEOPLASTIC AGENTS
§ ANTIANDROGENS
bicalutamide
§ MISCELLANEOUS
VISTOGARD
CARDIOVASCULAR
§ ACE INHIBITORS
fosinopril lisinopril quinapril ramipril
§ ACE INHIBITOR / DIURETIC COMBINATIONS
fosinopril-hydrochlorothiazide
lisinopril-hydrochlorothiazide
quinapril-hydrochlorothiazide
§ ANGIOTENSIN II RECEPTOR ANTAGONISTS / DIURETIC COMBINATIONS
candesartan / candesartan-hydrochlorothiazide
eprosartan
irbesartan / irbesartan-hydrochlorothiazide
losartan / losartan-hydrochlorothiazide
olmesartan / olmesartan-hydrochlorothiazide
telmisartan / telmisartan-hydrochlorothiazide
valsartan / valsartan-hydrochlorothiazide
§ ANGIOTENSIN II RECEPTOR ANTAGONIST / CALCIUM CHANNEL BLOCKER COMBINATIONS
amlodipine-olmesartan
amlodipine-telmisartan
amlodipine-valsartan
§ ANGIOTENSIN II RECEPTOR ANTAGONIST / CALCIUM CHANNEL BLOCKER / DIURETIC COMBINATIONS
amlodipine-valsartan-hydrochlorothiazide
olmesartan-amlodipine-hydrochlorothiazide
§ ANTIARRHYTHMICS
sotalol MULTAQ
ANTILIPEMICS
§ BILE ACID RESINS
cholestyramine
colesevelam
§ CHOLESTEROL ABSORPTION INHIBITORS
ezetimibe
§ FIBRATES
fenofibrate 3
fenofibric acid
§ HMG-CoA REDUCTASE INHIBITORS / COMBINATIONS
atorvastatin
ezetimibe-simvastatin
fluvastatin
lovastatin
pravastatin
rosuvastatin
simvastatin
§ NIACINS
niacin ext-rel
§ OMEGA-3 FATTY ACIDS
omega-3 acid ethyl esters
VASCEPA
§ BETA-BLOCKERS
atenolol carvedilol carvedilol phosphate ext-rel metoprolol succinate ext-rel metoprolol tartrate
nadolol pindolol propranolol propranolol ext-rel BYSTOLIC
§ CALCIUM CHANNEL BLOCKERS
amlodipine
diltiazem ext-rel 4
nifedipine ext-rel verapamil ext-rel
§ CALCIUM CHANNEL BLOCKER / ANTILIPEMIC COMBINATIONS
amlodipine-atorvastatin
§ DIGITALIS GLYCOSIDES
digoxin
DIRECT RENIN INHIBITORS / DIURETIC COMBINATIONS
TEKTURNA / TEKTURNA HCT
§ DIURETICS
amiloride
furosemide
hydrochlorothiazide
metolazone
spironolactone-hydrochlorothiazide
torsemide
triamterene-hydrochlorothiazide
HEART FAILURE
BIDIL
CORLANOR
ENTRESTO
§ NITRATES
nitroglycerin lingual spray
nitroglycerin sublingual
§ MISCELLANEOUS
RANEXA
CENTRAL NERVOUS
SYSTEM
§ ANTICONVULSANTS
carbamazepine
carbamazepine ext-rel diazepam rectal gel divalproex sodium
divalproex sodium ext-rel ethosuximide
gabapentin
lamotrigine
lamotrigine ext-rel levetiracetam
levetiracetam ext-rel oxcarbazepine
phenobarbital phenytoin
phenytoin sodium extended
primidone
tiagabine
topiramate
valproic acid
zonisamide
FYCOMPA
OXTELLAR XR
TROKENDI XR
VIMPAT
§ ANTIDEMENTIA
donepezil galantamine
galantamine ext-rel memantine
rivastigmine
rivastigmine transdermal NAMZARIC
ANTIDEPRESSANTS
§ SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)
citalopram
escitalopram
fluoxetine
paroxetine HCl paroxetine HCl ext-rel sertraline
TRINTELLIX
VIIBRYD
§ SEROTONIN NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs)
desvenlafaxine ext-rel duloxetine
venlafaxine
venlafaxine ext-rel capsule
§ MISCELLANEOUS AGENTS
bupropion
bupropion ext-rel mirtazapine
trazodone
§ ANTIPARKINSONIAN AGENTS
amantadine
carbidopa-levodopa
carbidopa-levodopa ext-rel carbidopa-levodopa-
entacapone
entacapone
pramipexole
pramipexole ext-rel rasagiline
ropinirole
ropinirole ext-rel selegiline
NEUPRO
ANTIPSYCHOTICS
§ ATYPICALS
aripiprazole
clozapine
olanzapine
quetiapine
quetiapine ext-rel risperidone
ziprasidone
ABILIFY MAINTENA
ARISTADA
ARISTADA INITIO
LATUDA
VRAYLAR
§ ATTENTION DEFICIT HYPERACTIVITY DISORDER
amphetamine-dextroamphetamine mixed salts
amphetamine-dextroamphetamine mixed salts ext-rel
atomoxetine
guanfacine ext-rel methylphenidate
methylphenidate ext-rel MYDAYIS
VYVANSE
FIBROMYALGIA
LYRICA
HYPNOTICS
§ NONBENZODIAZEPINES
eszopiclone
zolpidem
zolpidem ext-rel zolpidem sublingual BELSOMRA
TRICYCLICS
SILENOR
MIGRAINE
§ ERGOTAMINE DERIVATIVES
ergotamine-caffeine
MONOCLONAL ANTIBODIES
AJOVY
EMGALITY
§ SELECTIVE SEROTONIN AGONISTS
eletriptan
naratriptan
rizatriptan
sumatriptan
zolmitriptan
ONZETRA XSAIL
ZEMBRACE SYMTOUCH
ZOMIG NASAL SPRAY
SELECTIVE SEROTONIN AGONIST / NONSTEROIDAL ANTI-INFLAMMATORY DRUG (NSAID) COMBINATIONS
TREXIMET
§ MUSCULOSKELETAL THERAPY AGENTS
cyclobenzaprine
§ NARCOLEPSY
armodafinil
POSTHERPETIC NEURALGIA (PHN)
GRALISE
PSYCHOTHERAPEUTIC - MISCELLANEOUS
§ OPIOID ANTAGONISTS
naloxone injection
NARCAN NASAL SPRAY
§ PARTIAL OPIOID AGONIST / OPIOID ANTAGONIST COMBINATIONS
buprenorphine-naloxone sublingual tablet
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit Caremark.com or contact a CVS Caremark Customer Care representative.
SUBOXONE FILM
ZUBSOLV
PSEUDOBULBAR AFFECT AGENTS
NUEDEXTA
§ VASOMOTOR SYMPTOM AGENTS
paroxetine mesylate
ENDOCRINE AND
METABOLIC
§ ANDROGENS
testosterone gel testosterone solution
ANDRODERM
ANDROGEL 1.62%
ANTIDIABETICS
AMYLIN ANALOGS
SYMLINPEN
§ BIGUANIDES
metformin
metformin ext-rel 5
§ BIGUANIDE / SULFONYLUREA COMBINATIONS
glipizide-metformin
DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS
JANUVIA
DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR / BIGUANIDE COMBINATIONS
JANUMET
JANUMET XR
INCRETIN MIMETIC AGENTS
OZEMPIC
TRULICITY
VICTOZA
INCRETIN MIMETIC AGENT / INSULIN COMBINATIONS
SOLIQUA
INSULINS
BASAGLAR
FIASP
HUMULIN R U-500
LEVEMIR
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG MIX 70/30
TRESIBA
§ INSULIN SENSITIZERS
pioglitazone
§ INSULIN SENSITIZER / BIGUANIDE COMBINATIONS
pioglitazone-metformin
§ INSULIN SENSITIZER / SULFONYLUREA COMBINATIONS
pioglitazone-glimepiride
§ MEGLITINIDES
nateglinide
repaglinide
SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS
FARXIGA
JARDIANCE
SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR / BIGUANIDE COMBINATIONS
SYNJARDY
SYNJARDY XR
XIGDUO XR
SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR / DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR COMBINATIONS
GLYXAMBI QTERN
§ SULFONYLUREAS
glimepiride
glipizide
glipizide ext-rel
SUPPLIES
ACCU-CHEK AVIVA PLUS STRIPS AND KITS 6
ACCU-CHEK COMPACT PLUS STRIPS AND KITS 6
ACCU-CHEK GUIDE STRIPS AND KITS 6
ACCU-CHEK SMARTVIEW STRIPS AND KITS 6
BD ULTRAFINE INSULIN SYRINGES AND NEEDLES
DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM
OMNIPOD INSULIN INFUSION PUMP
V-GO INSULIN INFUSION PUMP
ANTIOBESITY
INJECTABLE
SAXENDA
ORAL
BELVIQ
BELVIQ XR
CALCIUM REGULATORS
§ BISPHOSPHONATES
alendronate
ibandronate
risedronate
§ CALCITONINS
calcitonin-salmon
§ CARNITINE DEFICIENCY AGENTS
levocarnitine
CONTRACEPTIVES
§ MONOPHASIC
ethinyl estradiol-drospirenone
ethinyl estradiol-drospirenone-levomefolate
ethinyl estradiol-norethindrone acetate
ethinyl estradiol-norethindrone acetate-iron
SAFYRAL
§ BIPHASIC
LO LOESTRIN FE
§ TRIPHASIC
ethinyl estradiol-norgestimate
FOUR PHASE
NATAZIA
§ EXTENDED CYCLE
ethinyl estradiol-levonorgestrel
§ TRANSDERMAL
ethinyl estradiol-norelgestromin
VAGINAL
NUVARING
ENDOMETRIOSIS
ORILISSA
ESTROGENS
§ ORAL
estradiol PREMARIN
§ TRANSDERMAL
estradiol DIVIGEL
EVAMIST
MINIVELLE
§ VAGINAL
estradiol ESTRING
PREMARIN CREAM
ESTROGEN / PROGESTINS
§ ORAL
estradiol-norethindrone
PREMPHASE
PREMPRO
TRANSDERMAL
CLIMARA PRO
COMBIPATCH
ESTROGEN / SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS
DUAVEE
§ GLUCOCORTICOIDS
dexamethasone
fludrocortisone
hydrocortisone
methylprednisolone
prednisolone solution
prednisone
GLUCOSE ELEVATING AGENTS
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
§ PHOSPHATE BINDER AGENTS
calcium acetate
lanthanum carbonate
sevelamer carbonate
PHOSLYRA
VELPHORO
POTASSIUM-REMOVING AGENTS
LOKELMA
VELTASSA
PROGESTINS
§ ORAL
medroxyprogesterone
megestrol acetate
progesterone, micronized
VAGINAL
CRINONE
ENDOMETRIN
§ SELECTIVE ESTROGEN RECEPTOR MODULATORS
raloxifene
OSPHENA
§ THYROID SUPPLEMENTS
levothyroxine
liothyronine
SYNTHROID
GASTROINTESTINAL
§ ANTIEMETICS
dronabinol granisetron
meclizine
metoclopramide
ondansetron
prochlorperazine
promethazine
trimethobenzamide
DICLEGIS
SANCUSO
VARUBI
§ ANTISPASMODICS
dicyclomine
§ H2 RECEPTOR ANTAGONISTS
ranitidine
INFLAMMATORY BOWEL DISEASE
§ ORAL AGENTS
balsalazide
budesonide capsule
budesonide ext-rel sulfasalazine
sulfasalazine delayed-rel APRISO
LIALDA
PENTASA
§ RECTAL AGENTS
hydrocortisone enema
mesalamine rectal suspension
CORTIFOAM
§ IRRITABLE BOWEL SYNDROME
alosetron
AMITIZA
LINZESS
VIBERZI
§ LAXATIVES
lactulose solution
peg 3350-electrolytes
SUPREP
OPIOID-INDUCED CONSTIPATION
MOVANTIK
PANCREATIC ENZYMES
CREON
VIOKACE
ZENPEP
§ PROTON PUMP INHIBITORS
esomeprazole
lansoprazole
omeprazole
pantoprazole
DEXILANT
§ STEROIDS, RECTAL
PROCTOFOAM-HC
§ ULCER THERAPY COMBINATIONS
PYLERA
GENITOURINARY
§ BENIGN PROSTATIC HYPERPLASIA
alfuzosin ext-rel doxazosin
dutasteride
dutasteride-tamsulosin
finasteride
silodosin
tamsulosin
terazosin
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit Caremark.com or contact a CVS Caremark Customer Care representative.
ERECTILE DYSFUNCTION
ALPROSTADIL AGENTS
MUSE
§ PHOSPHODIESTERASE INHIBITORS
sildenafil tadalafil
§ URINARY ANTISPASMODICS
darifenacin ext-rel oxybutynin
oxybutynin ext-rel tolterodine
tolterodine ext-rel trospium
trospium ext-rel MYRBETRIQ
TOVIAZ
VESICARE
HEMATOLOGIC
§ ANTICOAGULANTS
warfarin
ELIQUIS
XARELTO
§ PLATELET AGGREGATION INHIBITORS
clopidogrel dipyridamole ext-rel-aspirin
prasugrel BRILINTA
IMMUNOLOGIC
AGENTS
ALLERGENIC EXTRACTS
GRASTEK
RAGWITEK
NUTRITIONAL /
SUPPLEMENTS
§ ELECTROLYTES
potassium chloride liquid
VITAMINS AND MINERALS
§ FOLIC ACID / COMBINATIONS
folic acid
§ PRENATAL VITAMINS
prenatal vitamins
CITRANATAL
RESPIRATORY
§ ANAPHYLAXIS TREATMENT AGENTS
epinephrine auto-injector EPIPEN
EPIPEN JR
§ ANTICHOLINERGICS
ipratropium inhalation solution
INCRUSE ELLIPTA
SPIRIVA
ANTICHOLINERGIC / BETA AGONIST COMBINATIONS
§ SHORT ACTING
ipratropium-albuterol inhalation solution
COMBIVENT RESPIMAT
LONG ACTING
ANORO ELLIPTA
BEVESPI AEROSPHERE
STIOLTO RESPIMAT
ANTICHOLINERGIC / BETA AGONIST / STEROID INHALANT COMBINATIONS
TRELEGY ELLIPTA
§ ANTIHISTAMINES, LOW SEDATING
levocetirizine
§ ANTITUSSIVES
benzonatate (except NDCs^
69336012615, 69499032915)
BETA AGONISTS, INHALANTS
§ SHORT ACTING
albuterol inhalation solution
levalbuterol tartrate CFC-free aerosol
PROAIR HFA
PROAIR RESPICLICK
LONG ACTING
Hand-held Active Inhalation
SEREVENT
STRIVERDI RESPIMAT
Nebulized Passive Inhalation
PERFOROMIST
§ LEUKOTRIENE MODULATORS
montelukast zafirlukast zileuton ext-rel
§ NASAL ANTIHISTAMINES
azelastine
olopatadine
§ NASAL STEROIDS / COMBINATIONS
flunisolide
fluticasone
mometasone
triamcinolone
DYMISTA
PHOSPHODIESTERASE-4 INHIBITORS
DALIRESP
STEROID / BETA AGONIST COMBINATIONS
ADVAIR
BREO ELLIPTA
SYMBICORT
§ STEROID INHALANTS
budesonide inhalation suspension
ARNUITY ELLIPTA
ASMANEX
FLOVENT DISKUS
FLOVENT HFA
PULMICORT FLEXHALER
QVAR
QVAR REDIHALER
TOPICAL
DERMATOLOGY
ACNE
§ Topical
adapalene
benzoyl peroxide
clindamycin solution
clindamycin-benzoyl peroxide
erythromycin solution
erythromycin-benzoyl peroxide
tretinoin
DIFFERIN
EPIDUO
RETIN-A MICRO
TAZORAC
§ ACTINIC KERATOSIS
fluorouracil cream 5%
fluorouracil solution
imiquimod
PICATO
TOLAK
ZYCLARA
§ ANTIFUNGALS
ciclopirox
clotrimazole
econazole
ketoconazole
luliconazole
nystatin
JUBLIA
NAFTIN
§ ANTIPSORIATICS
acitretin
calcipotriene ointment, solution
methoxsalen
§ ATOPIC DERMATITIS
tacrolimus
ELIDEL
EUCRISA
CORTICOSTEROIDS
§ Low Potency
desonide
hydrocortisone
§ Medium Potency
clocortolone
hydrocortisone butyrate
mometasone
triamcinolone
§ High Potency
desoximetasone
fluocinonide 7
§ Very High Potency
clobetasol cream, foam, gel, lotion, ointment, shampoo
§ LOCAL ANESTHETICS
lidocaine-prilocaine
§ ROSACEA
metronidazole
FINACEA
ORACEA
SOOLANTRA
MOUTH / THROAT / DENTAL AGENTS
PROTECTANTS
EPISIL
OPHTHALMIC
§ ANTIALLERGICS
azelastine
cromolyn sodium
olopatadine
LASTACAFT
PAZEO
§ ANTI-INFECTIVES
ciprofloxacin
erythromycin
gentamicin
levofloxacin
moxifloxacin
ofloxacin
sulfacetamide
tobramycin
BESIVANCE
CILOXAN OINTMENT
MOXEZA
§ ANTI-INFECTIVE / ANTI-INFLAMMATORY COMBINATIONS
neomycin-polymyxin B-bacitracin-hydrocortisone
neomycin-polymyxin B-dexamethasone
tobramycin-dexamethasone
TOBRADEX OINTMENT
TOBRADEX ST
ZYLET
ANTI-INFLAMMATORIES
§ Nonsteroidal
bromfenac
diclofenac
ketorolac
ACUVAIL
ILEVRO
NEVANAC
§ Steroidal
dexamethasone
prednisolone acetate 1%
DUREZOL
FLAREX
FML FORTE
FML S.O.P. MAXIDEX
PRED MILD
BETA-BLOCKERS
§ Nonselective
timolol maleate solution
BETIMOL
Selective
BETOPTIC S
§ CARBONIC ANHYDRASE INHIBITORS
dorzolamide
AZOPT
§ CARBONIC ANHYDRASE INHIBITOR / BETA-BLOCKER COMBINATIONS
dorzolamide-timolol
CARBONIC ANHYDRASE INHIBITOR / SYMPATHOMIMETIC COMBINATIONS
SIMBRINZA
DRY EYE DISEASE
RESTASIS
XIIDRA
§ PROSTAGLANDINS
latanoprost LUMIGAN
TRAVATAN Z
RHO KINASE INHIBITORS
RHOPRESSA
§ SYMPATHOMIMETICS
brimonidine
ALPHAGAN P
SYMPATHOMIMETIC / BETA-BLOCKER COMBINATIONS
COMBIGAN
OTIC
§ ANTI-INFECTIVE / ANTI-INFLAMMATORY COMBINATIONS
CIPRODEX
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit Caremark.com or contact a CVS Caremark Customer Care representative.
QUICK REFERENCE DRUG LIST
A
ABILIFY MAINTENA
ABSTRAL
ACCU-CHEK AVIVA PLUS STRIPS AND KITS 6
ACCU-CHEK COMPACT PLUS STRIPS AND KITS 6
ACCU-CHEK GUIDE STRIPS AND KITS 6
ACCU-CHEK SMARTVIEW STRIPS AND KITS 6
acitretin
ACUVAIL
acyclovir adapalene
ADVAIR
AJOVY
albuterol inhalation solution
alendronate
alfuzosin ext-rel allopurinol alosetron
ALPHAGAN P
amantadine
amiloride
AMITIZA
amlodipine
amlodipine-atorvastatin
amlodipine-olmesartan
amlodipine-telmisartan
amlodipine-valsartan
amlodipine-valsartan-hydrochlorothiazide
amoxicillin
amoxicillin-clavulanate
amphetamine-dextroamphetamine mixed salts
amphetamine-dextroamphetamine mixed salts ext-rel
ANDRODERM
ANDROGEL 1.62%
ANORO ELLIPTA
APRISO
aripiprazole
ARISTADA
ARISTADA INITIO
armodafinil ARNUITY ELLIPTA
ASMANEX
atenolol atomoxetine
atorvastatin
azelastine
azithromycin
AZOPT
B
balsalazide
BASAGLAR
BD ULTRAFINE INSULIN SYRINGES AND NEEDLES
BELBUCA
BELSOMRA
BELVIQ
BELVIQ XR
benzonatate (except NDCs^
69336012615, 69499032915)
benzoyl peroxide
BESIVANCE
BETIMOL
BETOPTIC S
BEVESPI AEROSPHERE
bicalutamide
BIDIL
BREO ELLIPTA
BRILINTA
brimonidine
bromfenac
budesonide capsule
budesonide ext-rel budesonide
inhalation suspension
buprenorphine-naloxone sublingual tablet
bupropion
bupropion ext-rel BUTRANS
BYSTOLIC
C
calcipotriene ointment, solution
calcitonin-salmon
calcium acetate
candesartan
candesartan-hydrochlorothiazide
carbamazepine
carbamazepine ext-rel carbidopa-levodopa
carbidopa-levodopa ext-rel carbidopa-levodopa-
entacapone
carvedilol carvedilol phosphate ext-rel cefdinir cefprozil cefuroxime axetil celecoxib
cephalexin
cholestyramine
ciclopirox
CILOXAN OINTMENT
CIPRODEX
ciprofloxacin
ciprofloxacin ext-rel citalopram
CITRANATAL
clarithromycin
clarithromycin ext-rel CLIMARA PRO
clindamycin
clindamycin solution
clindamycin-benzoyl peroxide
clobetasol cream, foam, gel, lotion, ointment, shampoo
clocortolone
clopidogrel clotrimazole
clozapine
codeine-acetaminophen
colchicine tablet COLCRYS
colesevelam
COMBIGAN
COMBIPATCH
COMBIVENT RESPIMAT
CORLANOR
CORTIFOAM
CREON
CRINONE
cromolyn sodium
cyclobenzaprine
D
DALIRESP
darifenacin ext-rel desonide
desoximetasone
desvenlafaxine ext-rel dexamethasone
DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM
DEXILANT
diazepam rectal gel DICLEGIS
diclofenac
diclofenac sodium
diclofenac sodium
gel 1% (except NDC^
69499031866)
diclofenac sodium solution
diclofenac sodium-misoprostol
dicloxacillin
dicyclomine
DIFFERIN
DIFICID
digoxin
diltiazem ext-rel 4
dipyridamole ext-rel-aspirin
divalproex sodium
divalproex sodium ext-rel DIVIGEL
donepezil dorzolamide
dorzolamide-timolol doxazosin
doxycycline hyclate
dronabinol DUAVEE
duloxetine
DUREZOL
dutasteride
dutasteride-tamsulosin
DYMISTA
E
econazole
eletriptan
ELIDEL
ELIQUIS
EMBEDA
EMGALITY
EMVERM
ENDOMETRIN
entacapone
ENTRESTO
EPIDUO
epinephrine auto-injector EPIPEN
EPIPEN JR
EPISIL
eprosartan
ergotamine-caffeine
erythromycin
erythromycin solution
erythromycin-benzoyl peroxide
erythromycins
escitalopram
esomeprazole
estradiol estradiol-norethindrone
ESTRING
eszopiclone
ethinyl estradiol-drospirenone
ethinyl estradiol-drospirenone-levomefolate
ethinyl estradiol-levonorgestrel
ethinyl estradiol-norelgestromin
ethinyl estradiol-norethindrone acetate
ethinyl estradiol-norethindrone acetate-iron
ethinyl estradiol-norgestimate
ethosuximide
EUCRISA
EVAMIST
ezetimibe
ezetimibe-simvastatin
F
FARXIGA
fenofibrate 3
fenofibric acid
fentanyl transdermal fentanyl transmucosal
lozenge
FIASP
FINACEA
finasteride
FLAREX
FLOVENT DISKUS
FLOVENT HFA
fluconazole
fludrocortisone
flunisolide
fluocinonide 7
fluorouracil cream 5%
fluorouracil solution
fluoxetine
fluticasone
fluvastatin
FML FORTE
FML S.O.P. folic acid
fosinopril fosinopril-hydrochlorothiazide
furosemide
FYCOMPA
G
gabapentin
galantamine
galantamine ext-rel gentamicin
glimepiride
glipizide
glipizide ext-rel glipizide-metformin
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
GLYXAMBI GRALISE
granisetron
GRASTEK
guanfacine ext-rel
H
HUMULIN R U-500
hydrochlorothiazide
hydrocodone-acetaminophen
hydrocortisone
hydrocortisone butyrate
hydrocortisone enema
hydromorphone
hydromorphone ext-rel HYSINGLA ER
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit Caremark.com or contact a CVS Caremark Customer Care representative.
I
ibandronate
ibuprofen suspension
ILEVRO
imiquimod
INCRUSE ELLIPTA
ipratropium inhalation solution
ipratropium-albuterol inhalation solution
irbesartan
irbesartan-hydrochlorothiazide
itraconazole
ivermectin
J
JANUMET
JANUMET XR
JANUVIA
JARDIANCE
JUBLIA
K
ketoconazole
ketorolac
L
lactulose solution
lamotrigine
lamotrigine ext-rel lansoprazole
lanthanum carbonate
LASTACAFT
latanoprost LATUDA
levalbuterol tartrate CFC-free aerosol
LEVEMIR
levetiracetam
levetiracetam ext-rel levocarnitine
levocetirizine
levofloxacin
levothyroxine
LIALDA
lidocaine-prilocaine
linezolid
LINZESS
liothyronine
lisinopril lisinopril-hydrochlorothiazide
LO LOESTRIN FE
LOKELMA
losartan
losartan-hydrochlorothiazide
lovastatin
luliconazole
LUMIGAN
LYRICA
M
MAXIDEX
meclizine
medroxyprogesterone
megestrol acetate
meloxicam
memantine
mesalamine rectal suspension
metformin
metformin ext-rel 5
methadone
methoxsalen
methylphenidate
methylphenidate ext-rel methylprednisolone
metoclopramide
metolazone
metoprolol succinate ext-rel metoprolol tartrate
metronidazole
MINIVELLE
minocycline
mirtazapine
mometasone
montelukast morphine
morphine ext-rel morphine suppository
MOVANTIK
MOXEZA
moxifloxacin
MULTAQ
MUSE
MYDAYIS
MYRBETRIQ
N
nadolol NAFTIN
naloxone injection
NAMZARIC
naproxen 2
naratriptan
NARCAN NASAL SPRAY
NATAZIA
nateglinide
neomycin-polymyxin B-bacitracin-hydrocortisone
neomycin-polymyxin B-dexamethasone
NEUPRO
NEVANAC
niacin ext-rel nifedipine ext-rel nitrofurantoin
nitroglycerin lingual spray
nitroglycerin sublingual NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG MIX 70/30
NUCYNTA
NUCYNTA ER
NUEDEXTA
NUVARING
nystatin
O
ofloxacin
olanzapine
olmesartan
olmesartan-amlodipine-hydrochlorothiazide
olmesartan-hydrochlorothiazide
olopatadine
omega-3 acid ethyl esters
omeprazole
OMNIPOD INSULIN INFUSION PUMP
ondansetron
ONZETRA XSAIL
ORACEA
ORILISSA
oseltamivir OSPHENA
oxcarbazepine
OXTELLAR XR
oxybutynin
oxybutynin ext-rel oxycodone
oxycodone-acetaminophen
OXYCONTIN
OZEMPIC
P
pantoprazole
paroxetine HCl paroxetine HCl ext-rel paroxetine mesylate
PAZEO
peg 3350-electrolytes
penicillin VK
PENTASA
PERFOROMIST
phenobarbital phenytoin
phenytoin sodium extended
PHOSLYRA
PICATO
pindolol pioglitazone
pioglitazone-glimepiride
pioglitazone-metformin
potassium chloride liquid
pramipexole
pramipexole ext-rel prasugrel pravastatin
PRED MILD
prednisolone acetate 1%
prednisolone solution
prednisone
PREMARIN
PREMARIN CREAM
PREMPHASE
PREMPRO
prenatal vitamins
primidone
PROAIR HFA
PROAIR RESPICLICK
probenecid
prochlorperazine
PROCTOFOAM-HC
progesterone, micronized
promethazine
propranolol propranolol ext-rel PULMICORT FLEXHALER
PYLERA
Q
QTERN
quetiapine
quetiapine ext-rel quinapril quinapril-hydrochlorothiazide
QVAR
QVAR REDIHALER
R
RAGWITEK
raloxifene
ramipril RANEXA
ranitidine
rasagiline
RELENZA
repaglinide
RESTASIS
RETIN-A MICRO
RHOPRESSA
risedronate
risperidone
rivastigmine
rivastigmine transdermal rizatriptan
ropinirole
ropinirole ext-rel rosuvastatin
S
SAFYRAL
SANCUSO
SAXENDA
selegiline
SEREVENT
sertraline
sevelamer carbonate
sildenafil SILENOR
silodosin
SIMBRINZA
simvastatin
SOLIQUA
SOOLANTRA
sotalol SPIRIVA
spironolactone-hydrochlorothiazide
STIOLTO RESPIMAT
STRIVERDI RESPIMAT
SUBOXONE FILM
SUBSYS
sulfacetamide
sulfamethoxazole-trimethoprim
sulfasalazine
sulfasalazine delayed-rel sumatriptan
SUPRAX
SUPREP
SYMBICORT
SYMLINPEN
SYNJARDY
SYNJARDY XR
SYNTHROID
T
tacrolimus
tadalafil tamsulosin
TAZORAC
TEKTURNA
TEKTURNA HCT
telmisartan
telmisartan-hydrochlorothiazide
terazosin
terbinafine tablet testosterone gel testosterone solution
tetracycline
tiagabine
timolol maleate solution
TOBRADEX OINTMENT
TOBRADEX ST
tobramycin
tobramycin-dexamethasone
TOLAK
tolterodine
tolterodine ext-rel topiramate
torsemide
TOVIAZ
tramadol tramadol ext-rel TRAVATAN Z
trazodone
TRELEGY ELLIPTA
TRESIBA
tretinoin
TREXIMET
triamcinolone
triamterene-hydrochlorothiazide
trimethobenzamide
TRINTELLIX
TROKENDI XR
trospium
trospium ext-rel TRULICITY
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit Caremark.com or contact a CVS Caremark Customer Care representative.
U
ULORIC
V
valacyclovir valganciclovir valproic acid
valsartan
valsartan-hydrochlorothiazide
VARUBI VASCEPA
VELPHORO
VELTASSA
venlafaxine
venlafaxine ext-rel capsule
verapamil ext-rel VESICARE
V-GO INSULIN INFUSION PUMP
VIBERZI VICTOZA
VIIBRYD
VIMPAT
VIOKACE
VISTOGARD
VRAYLAR
VYVANSE
W
warfarin
X
XARELTO
XIFAXAN 550 MG
XIGDUO XR
XIIDRA
Z
zafirlukast ZEMBRACE SYMTOUCH
ZENPEP
zileuton ext-rel
ziprasidone
zolmitriptan
zolpidem
zolpidem ext-rel zolpidem sublingual ZOMIG NASAL SPRAY
zonisamide
ZUBSOLV
ZYCLARA
ZYLET
PREFERRED OPTIONS LIST
DRUG NAME(S) PREFERRED OPTION(S)*
ABILIFY aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, LATUDA, VRAYLAR
ACANYA adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC
ACTICLATE doxycycline hyclate, minocycline, tetracycline
ACTOS pioglitazone
ADDERALL XR amphetamine-dextroamphetamine mixed salts ext-rel, methylphenidate ext-rel, MYDAYIS, VYVANSE
ALCORTIN A desonide, hydrocortisone
Alevicyn solution, ALEVICYN GEL, ALEVICYN KIT, ALEVICYN SG
desonide, hydrocortisone
ALLISON MEDICAL INSULIN SYRINGES 9 BD ULTRAFINE INSULIN SYRINGES
ALORA estradiol, DIVIGEL, EVAMIST, MINIVELLE
ALTOPREV atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin
ALVESCO ARNUITY ELLIPTA, ASMANEX, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR, QVAR REDIHALER
AMRIX cyclobenzaprine
ANDROGEL 1% testosterone gel, testosterone solution, ANDRODERM, ANDROGEL 1.62%
ANGELIQ estradiol-norethindrone, PREMPHASE, PREMPRO
ANTARA fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid
APEXICON E desoximetasone, fluocinonide (except fluocinonide cream 0.1%)
APIDRA FIASP, NOVOLOG
ARMOUR THYROID levothyroxine, liothyronine, SYNTHROID
ARTHROTEC celecoxib; diclofenac sodium, meloxicam or naproxen (except naproxen CR or naproxen suspension) WITH esomeprazole, lansoprazole, omeprazole, pantoprazole or DEXILANT
ASACOL HD balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA
DRUG NAME(S) PREFERRED OPTION(S)*
ASCENSIA STRIPS AND KITS 8 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 6, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 6, ACCU-CHEK GUIDE STRIPS AND KITS 6, ACCU-CHEK SMARTVIEW STRIPS AND KITS 6
ATACAND, ATACAND HCT candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide
ATROVENT HFA ipratropium inhalation solution, INCRUSE ELLIPTA, SPIRIVA
AVENOVA Consult doctor
AZELEX adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC
BECONASE AQ flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA
BENICAR, BENICAR HCT candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide
BENSAL HP desonide, hydrocortisone
BENZAC AC adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC
BENZACLIN adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC
BENZIQ adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC
benzonatate (NDCs^ 69336012615, 69499032915 only)
benzonatate (except NDCs^ 69336012615, 69499032915)
BETAPACE, BETAPACE AF sotalol
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit Caremark.com or contact a CVS Caremark Customer Care representative.
DRUG NAME(S) PREFERRED OPTION(S)*
BREEZE 2 STRIPS AND KITS 8 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 6, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 6, ACCU-CHEK GUIDE STRIPS AND KITS 6, ACCU-CHEK SMARTVIEW STRIPS AND KITS 6
butalbital-acetaminophen (NDC^ 69499034230 only)
diclofenac sodium, naproxen (except naproxen CR or naproxen suspension)
butalbital-acetaminophen-caffeine capsule diclofenac sodium, naproxen (except naproxen CR or naproxen suspension)
BYDUREON OZEMPIC, TRULICITY, VICTOZA
BYETTA OZEMPIC, TRULICITY, VICTOZA
CAFERGOT eletriptan, ergotamine-caffeine, naratriptan, rizatriptan, sumatriptan, zolmitriptan, ONZETRA XSAIL, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY
calcipotriene cream calcipotriene ointment, calcipotriene solution
calcitriol ointment calcipotriene ointment, calcipotriene solution
CAMBIA diclofenac sodium, meloxicam, naproxen (except naproxen CR or naproxen suspension)
CARAC fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, TOLAK, ZYCLARA
carbinoxamine tablet 6 mg levocetirizine
CARDIZEM diltiazem ext-rel (except generic CARDIZEM LA)
CARDIZEM CD diltiazem ext-rel (except generic CARDIZEM LA)
CARDIZEM LA (and its generics) diltiazem ext-rel (except generic CARDIZEM LA)
CARNITOR levocarnitine
CARNITOR SF levocarnitine
chlorzoxazone 250 mg (NDC^ 69499033060 only)
cyclobenzaprine
CHLORZOXAZONE 250 MG (NDC^ 46672086046 only)
cyclobenzaprine
CLINDAGEL erythromycin solution
clobetasol spray clobetasol foam
CLOBEX SPRAY clobetasol foam
COLAZAL balsalazide
CONTOUR NEXT STRIPS AND KITS 8 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 6, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 6, ACCU-CHEK GUIDE STRIPS AND KITS 6, ACCU-CHEK SMARTVIEW STRIPS AND KITS 6
CONTOUR STRIPS AND KITS 8 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 6, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 6, ACCU-CHEK GUIDE STRIPS AND KITS 6, ACCU-CHEK SMARTVIEW STRIPS AND KITS 6
CONTRAVE BELVIQ, BELVIQ XR, SAXENDA
CORDRAN OINTMENT clocortolone, hydrocortisone butyrate, mometasone, triamcinolone
CRESTOR atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin
CYMBALTA desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule
DELZICOL balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA
DRUG NAME(S) PREFERRED OPTION(S)*
DETROL LA darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ, VESICARE
Dexifol folic acid
Dexpak dexamethasone, hydrocortisone, methylprednisolone, prednisolone solution, prednisone
diclofenac sodium gel 1% (NDC^ 69499031866 only)
diclofenac sodium, diclofenac sodium gel 1% (except NDC^ 69499031866), diclofenac sodium solution, meloxicam, naproxen (except naproxen CR or naproxen suspension)
Diclofex DC (NDC^ 51021037201 only)
diclofenac sodium, diclofenac sodium gel 1% (except NDC^ 69499031866), diclofenac sodium solution, meloxicam, naproxen (except naproxen CR or naproxen suspension)
Diclosaicin diclofenac sodium, diclofenac sodium gel 1% (except NDC^ 69499031866), diclofenac sodium solution, meloxicam, naproxen (except naproxen CR or naproxen suspension)
diflorasone cream desoximetasone, fluocinonide (except fluocinonide cream 0.1%)
diflorasone ointment desoximetasone, fluocinonide (except fluocinonide cream 0.1%)
dihydroergotamine spray eletriptan, ergotamine-caffeine, naratriptan, rizatriptan, sumatriptan, zolmitriptan, ONZETRA XSAIL, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY
DIOVAN, DIOVAN HCT candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide
DORAL eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA, SILENOR
DORYX doxycycline hyclate, minocycline, tetracycline
DORYX MPC doxycycline hyclate, minocycline, tetracycline
doxepin cream desonide, hydrocortisone, tacrolimus, ELIDEL, EUCRISA
DULERA ADVAIR, BREO ELLIPTA, SYMBICORT
DUTOPROL metoprolol succinate ext-rel WITH hydrochlorothiazide
DYRENIUM amiloride
EDARBI, EDARBYCLOR candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide
EDLUAR eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA, SILENOR
E.E.S. GRANULES erythromycins
EFFEXOR XR desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit Caremark.com or contact a CVS Caremark Customer Care representative.
DRUG NAME(S) PREFERRED OPTION(S)*
ENABLEX darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ, VESICARE
ERYPED erythromycins
EVZIO naloxone injection, NARCAN NASAL SPRAY
EXFORGE amlodipine-olmesartan, amlodipine-telmisartan, amlodipine-valsartan
EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, olmesartan-amlodipine-hydrochlorothiazide
FANAPT aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, LATUDA, VRAYLAR
FEMRING estradiol, ESTRING, PREMARIN CREAM
fenofibrate tablet 120 mg fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid
FENOGLIDE TABLET 120 MG fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid
fenoprofen capsule diclofenac sodium, meloxicam, naproxen (except naproxen CR or naproxen suspension)
FENOPROFEN CAPSULE diclofenac sodium, meloxicam, naproxen (except naproxen CR or naproxen suspension)
FERIVA 21/7 folic acid
FETZIMA desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule
FIORICET CAPSULE diclofenac sodium, naproxen (except naproxen CR or naproxen suspension)
fluocinonide cream 0.1% clobetasol cream
fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, TOLAK, ZYCLARA
flurandrenolide ointment clocortolone, hydrocortisone butyrate, mometasone, triamcinolone
FML LIQUIFILM dexamethasone, prednisolone acetate 1%, DUREZOL, FLAREX, FML FORTE, FML S.O.P., MAXIDEX, PRED MILD
FOLIC-K folic acid
FOLIKA-D folic acid
Folika-T folic acid
FOLIKA-V folic acid
FORTAMET (and its generic) metformin, metformin ext-rel (except generic FORTAMET or GLUMETZA)
FORTESTA testosterone gel, testosterone solution, ANDRODERM, ANDROGEL 1.62%
FOSAMAX PLUS D alendronate, ibandronate, risedronate
FOSRENOL calcium acetate, lanthanum carbonate, sevelamer carbonate, PHOSLYRA, VELPHORO
FOSTEUM, FOSTEUM PLUS alendronate, ibandronate, risedronate
FREESTYLE STRIPS AND KITS 8 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 6, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 6, ACCU-CHEK GUIDE STRIPS AND KITS 6, ACCU-CHEK SMARTVIEW STRIPS AND KITS 6
DRUG NAME(S) PREFERRED OPTION(S)*
FROVA eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, ONZETRA XSAIL, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY
Genicin Vita-S folic acid
GLUMETZA (and its generic) metformin, metformin ext-rel (except generic FORTAMET or GLUMETZA)
GLYCOPYRROLATE TABLET 1.5 MG dicyclomine
HORIZANT gabapentin, GRALISE
HUMALOG FIASP, NOVOLOG
HUMALOG MIX 50/50 NOVOLOG MIX 70/30
HUMALOG MIX 75/25 NOVOLOG MIX 70/30
HUMULIN 70/30 NOVOLIN 70/30
HUMULIN N NOVOLIN N
HUMULIN R NOVOLIN R
hydrocortisone 1% in absorbase (NDCs^ 69499032210, 69499034325 only)
desonide, hydrocortisone
HylaVite folic acid
INDOCIN diclofenac sodium, meloxicam, naproxen (except naproxen CR or naproxen suspension)
Inflammacin diclofenac sodium, diclofenac sodium gel 1% (except NDC^ 69499031866), diclofenac sodium solution, meloxicam, naproxen (except naproxen CR or naproxen suspension)
INNOPRAN XL atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, propranolol, propranolol ext-rel, BYSTOLIC
INTERMEZZO eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA, SILENOR
INTUNIV amphetamine-dextroamphetamine mixed salts ext-rel, atomoxetine, guanfacine ext-rel, methylphenidate ext-rel, MYDAYIS, VYVANSE
INVOKAMET SYNJARDY, SYNJARDY XR, XIGDUO XR
INVOKAMET XR SYNJARDY, SYNJARDY XR, XIGDUO XR
INVOKANA FARXIGA, JARDIANCE
ISTALOL timolol maleate solution, BETIMOL
JALYN dutasteride-tamsulosin; dutasteride or finasteride WITH alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin
JENTADUETO JANUMET, JANUMET XR
JENTADUETO XR JANUMET, JANUMET XR
KAZANO JANUMET, JANUMET XR
KOMBIGLYZE XR JANUMET, JANUMET XR
lactulose pak lactulose solution
LANOXIN TABLET (125 MCG and 250 MCG only)
digoxin
LANTUS BASAGLAR, LEVEMIR, TRESIBA
LAZANDA fentanyl transmucosal lozenge, ABSTRAL, SUBSYS
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit Caremark.com or contact a CVS Caremark Customer Care representative.
DRUG NAME(S) PREFERRED OPTION(S)*
LESCOL XL atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin
levorphanol fentanyl transdermal, hydromorphone ext-rel, methadone, morphine ext-rel, EMBEDA, HYSINGLA ER, NUCYNTA ER, OXYCONTIN
LIDOCAINE-TETRACAINE CREAM lidocaine-prilocaine
LIDOTREX lidocaine-prilocaine
LIPITOR atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin
LIVALO atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin
Lorid folic acid
LUNESTA eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA, SILENOR
MACRODANTIN nitrofurantoin
Matzim LA diltiazem ext-rel (except generic CARDIZEM LA)
MEBOLIC folic acid
MENEST estradiol, PREMARIN
MENOSTAR estradiol
MIACALCIN INJECTION alendronate, calcitonin-salmon, ibandronate, risedronate, FORTEO, PROLIA, TYMLOS
MIACALCIN NASAL SPRAY calcitonin-salmon
MICARDIS, MICARDIS HCT candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide
MILLIPRED dexamethasone, hydrocortisone, methylprednisolone, prednisolone solution, prednisone
MINOCIN doxycycline hyclate, minocycline, tetracycline
NAPRELAN diclofenac sodium, meloxicam, naproxen (except naproxen CR or naproxen suspension)
naproxen CR diclofenac sodium, meloxicam, naproxen (except naproxen CR or naproxen suspension)
naproxen suspension ibuprofen suspension
NATESTO testosterone gel, testosterone solution, ANDRODERM, ANDROGEL 1.62%
NESINA JANUVIA
NEXIUM esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT
NICAPRIN folic acid
NICAZEL, NICAZEL FORTE folic acid
NILANDRON abiraterone, bicalutamide, XTANDI
NITROMIST nitroglycerin lingual spray, nitroglycerin sublingual
NORITATE metronidazole, FINACEA, SOOLANTRA
NORVASC amlodipine
NOVACORT desonide, hydrocortisone
DRUG NAME(S) PREFERRED OPTION(S)*
NOVO NORDISK NEEDLES 9 BD ULTRAFINE NEEDLES
NuDiclo SoluPak diclofenac sodium, diclofenac sodium gel 1% (except NDC^ 69499031866), diclofenac sodium solution, meloxicam, naproxen (except naproxen CR or naproxen suspension)
NuDiclo TabPak diclofenac sodium, diclofenac sodium gel 1% (except NDC^ 69499031866), diclofenac sodium solution, meloxicam, naproxen (except naproxen CR or naproxen suspension)
NUVIGIL armodafinil
OLEPTRO trazodone
OLUX-E clobetasol foam
omeprazole-sodium bicarbonate esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT
OMNARIS flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA
OMNIVEX folic acid
ONETOUCH ULTRA STRIPS AND KITS 8 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 6, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 6, ACCU-CHEK GUIDE STRIPS AND KITS 6, ACCU-CHEK SMARTVIEW STRIPS AND KITS 6
ONETOUCH VERIO STRIPS AND KITS 8 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 6, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 6, ACCU-CHEK GUIDE STRIPS AND KITS 6, ACCU-CHEK SMARTVIEW STRIPS AND KITS 6
ONEXTON adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC
ONGLYZA JANUVIA
ORTHO DF folic acid
OSENI JANUMET, JANUMET XR
OWEN MUMFORD NEEDLES 9 BD ULTRAFINE NEEDLES
OXYTROL darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ, VESICARE
PANCREAZE CREON, VIOKACE, ZENPEP
PENNSAID diclofenac sodium, diclofenac sodium gel 1% (except NDC^ 69499031866), diclofenac sodium solution, meloxicam, naproxen (except naproxen CR or naproxen suspension)
PERRIGO NEEDLES 9 BD ULTRAFINE NEEDLES
PERTZYE CREON, VIOKACE, ZENPEP
PEXEVA citalopram, escitalopram, fluoxetine, paroxetine HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX, VIIBRYD
PLAVIX clopidogrel, prasugrel, BRILINTA
PRADAXA warfarin, ELIQUIS, XARELTO
PRECISION XTRA STRIPS AND KITS 8 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 6, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 6, ACCU-CHEK GUIDE STRIPS AND KITS 6, ACCU-CHEK SMARTVIEW STRIPS AND KITS 6
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit Caremark.com or contact a CVS Caremark Customer Care representative.
DRUG NAME(S) PREFERRED OPTION(S)*
PRED FORTE dexamethasone, prednisolone acetate 1%, DUREZOL, FLAREX, FML FORTE, FML S.O.P., MAXIDEX, PRED MILD
PREFEST estradiol-norethindrone, PREMPHASE, PREMPRO
PRENATAL PLUS generic prenatal vitamins, CITRANATAL
PREVACID esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT
PRIMLEV hydrocodone-acetaminophen, hydromorphone, morphine, oxycodone-acetaminophen, NUCYNTA
PROTONIX esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT
PROTOPIC tacrolimus, ELIDEL, EUCRISA
PROVENTIL HFA levalbuterol tartrate CFC-free aerosol, PROAIR HFA, PROAIR RESPICLICK
PSORCON desoximetasone, fluocinonide (except fluocinonide cream 0.1%)
QNASL flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA
QSYMIA BELVIQ, BELVIQ XR, SAXENDA
RAYOS dexamethasone, hydrocortisone, methylprednisolone, prednisolone solution, prednisone
RELION INSULIN NOVOLIN INSULIN
RELISTOR MOVANTIK
RHEUMATE folic acid
RIBOZEL folic acid
RIMSO-50 Consult doctor
RIOMET metformin, metformin ext-rel (except generic FORTAMET or GLUMETZA)
ROZEREM eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA, SILENOR
SEROQUEL XR aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, LATUDA, VRAYLAR
SORILUX calcipotriene ointment, calcipotriene solution
SPRIX diclofenac sodium, meloxicam, naproxen (except naproxen CR or naproxen suspension)
STENDRA sildenafil, tadalafil
STRIANT testosterone gel, testosterone solution, ANDRODERM, ANDROGEL 1.62%
SURE-TEST STRIPS AND KITS 8 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 6, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 6, ACCU-CHEK GUIDE STRIPS AND KITS 6, ACCU-CHEK SMARTVIEW STRIPS AND KITS 6
SYNERDERM desonide, hydrocortisone
TALIVA folic acid
TARGADOX doxycycline hyclate, minocycline, tetracycline
TESTIM testosterone gel, testosterone solution, ANDRODERM, ANDROGEL 1.62%
testosterone gel 1% 10 testosterone gel, testosterone solution, ANDRODERM, ANDROGEL 1.62%
TIROSINT levothyroxine, SYNTHROID
DRUG NAME(S) PREFERRED OPTION(S)*
TOUJEO BASAGLAR, LEVEMIR, TRESIBA
TRADJENTA JANUVIA
TRICOR fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid
TRIGLIDE fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid
TRILIPIX fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid
TRIVIDIA INSULIN SYRINGES 9 BD ULTRAFINE INSULIN SYRINGES
TronVite folic acid
TRUETEST STRIPS AND KITS 8 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 6, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 6, ACCU-CHEK GUIDE STRIPS AND KITS 6, ACCU-CHEK SMARTVIEW STRIPS AND KITS 6
TRUETRACK STRIPS AND KITS 8 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 6, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 6, ACCU-CHEK GUIDE STRIPS AND KITS 6, ACCU-CHEK SMARTVIEW STRIPS AND KITS 6
TUDORZA INCRUSE ELLIPTA, SPIRIVA
ULTIMED INSULIN SYRINGES 9 BD ULTRAFINE INSULIN SYRINGES
ULTIMED NEEDLES 9 BD ULTRAFINE NEEDLES
UROXATRAL alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin
VALCYTE valganciclovir
VALTREX acyclovir, valacyclovir
VANATOL LQ diclofenac sodium, naproxen (except naproxen CR or naproxen suspension)
VANATOL S diclofenac sodium, naproxen (except naproxen CR or naproxen suspension)
Vanoxide-HC adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC
VASCULERA Consult doctor
VECTICAL calcipotriene ointment, calcipotriene solution
VELTIN adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC
venlafaxine ext-rel tablet (except 225 mg)
desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule
VENTOLIN HFA levalbuterol tartrate CFC-free aerosol, PROAIR HFA, PROAIR RESPICLICK
VIAGRA sildenafil, tadalafil
VITAFOL-ONE generic prenatal vitamins, CITRANATAL
VOGELXO testosterone gel, testosterone solution, ANDRODERM, ANDROGEL 1.62%
Xelitral diclofenac sodium, diclofenac sodium gel 1% (except NDC^ 69499031866), diclofenac sodium solution, meloxicam, naproxen (except naproxen CR or naproxen suspension)
XOLEGEL ciclopirox, ketoconazole
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit Caremark.com or contact a CVS Caremark Customer Care representative.
DRUG NAME(S) PREFERRED OPTION(S)*
XOPENEX HFA levalbuterol tartrate CFC-free aerosol, PROAIR HFA, PROAIR RESPICLICK
Xvite folic acid
XYZBAC folic acid
ZEGERID esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT
ZETIA ezetimibe
ZETONNA flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA
ZIANA adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC
ZOLPIMIST eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA, SILENOR
DRUG NAME(S) PREFERRED OPTION(S)*
ZONEGRAN carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT
ZORVOLEX diclofenac sodium, meloxicam, naproxen (except naproxen CR or naproxen suspension)
ZUPLENZ granisetron, ondansetron, SANCUSO
ZYFLO, ZYFLO CR montelukast, zafirlukast, zileuton ext-rel
ZYVIT folic acid
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit Caremark.com or contact a CVS Caremark Customer Care representative.
You may be responsible for the full cost of certain non-formulary products that are removed from coverage. Please check with your plan sponsor for more information.
FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. New-to-market products and new variations of products already in the marketplace will not be added to the formulary immediately. Each product will be evaluated for clinical appropriateness and cost-effectiveness. Recommended additions to the formulary will be presented to the CVS Caremark National Pharmacy and Therapeutics Committee (or other appropriate reviewing body) for review and approval. In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market. Specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. The member's prescription benefit plan may have a different copay1 for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Generics listed in therapeutic categories are for representational purposes only. Listed products may be available generically in certain strengths or dosage forms. Dosage forms on this list will be consistent with the category and use where listed. Log in to Caremark.com to check coverage and copay1 information for a specific medicine. An exception process may exist for specific clinical or regulatory circumstances that may require coverage of an excluded medication.
^ Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package size.
* The preferred options in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency.
§ Generics are available in this class and should be considered the first line of prescribing. 1 Copayment, copay or coinsurance means the amount a member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the
prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan. 2 Listing does not include naproxen CR or naproxen suspension. 3 Listing does not include fenofibrate tablet 120 mg. 4 Listing does not include generic CARDIZEM LA. 5 Listing does not include generic FORTAMET or GLUMETZA. 6 An ACCU-CHEK blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ACCU-CHEK. For more information on
how to obtain a blood glucose meter, call: 1-877-418-4746. 7 Listing does not include fluocinonide cream 0.1%. 8 ACCU-CHEK brand test strips are the only preferred options. 9 BD ULTRAFINE syringes and needles are the only preferred options. 10 Listing reflects the authorized generics for TESTIM and VOGELXO.
Plan member privacy is important to us. Our employees are trained regarding the appropriate way to handle members' private health information. CVS Caremark may receive rebates, discounts and service fees from pharmaceutical manufacturers for certain listed products. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Caremark. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable. The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission. ©2019 CVS Caremark. All rights reserved. 106-31697B 070119 v3 Caremark.com
